LC引起的医源性右肝管、副肝管损伤的诊治

目的 分析腹腔镜胆囊切除术（LC）造成的医源性右肝管、副肝管损伤的特点及防治,探讨术中胆道造影（intraoperative cholangiography,IOC）对术后胆道通畅度评级的影响。方法 回顾性分析南京医科大学第一附属医院2014年5月至2021年11月诊治的20例医源性右肝管、副肝管损伤患者的损伤类型和损伤原因、治疗及随访结果。20例中11例未行术中胆道造影（非IOC组）,9例行术中行胆道造影（IOC组）,对比两组术后胆道通畅度评级。结果 右肝管损伤16例：8例行I期修补置管支撑引流,其中5例双T管置入;4例单纯修补;3例右肝管横断延期行胆肠吻合术;1例右肝管误缝扎,远期因梗阻行胆肠Roux-en-Y吻合术失败改行PTCD。4例副肝管损伤中1例修补并置管引流,1例术中误夹闭后胆瘘二期行胆肠吻合术,2例直接夹闭。IOC组术后胆道通畅度评级A级8例、C级1例,非IOC组GP A级3例、B级4例、C级3例、D级1例;IOC组评级优于非IOC组（P<0.05）。术后随访6~133个月,远期右肝管结石形成2例,胆管炎3例,右肝萎缩1例。结论 充分认识右肝管及副肝管的解剖特点,术中及时发现损伤,并根据损伤类型、IOC情况等制定相应策略是提高LC医源性胆管损伤疗效的关键。

Diagnosis and treatment of iatrogenic right hepatic duct injury and accessory hepatic duct injury caused by laparoscopic cholecystectomy

Objective To analyze the characteristics, diagnosis and treatment of iatrogenic right hepatic duct (RHD) injury and accessory hepatic duct (AHD) injury caused by laparoscopic cholecystectomy (LC), and to explore the effect of intraoperative cholangiography (IOC) on postoperative grading of biliary patency. Methods A retrospective study was conducted on 20 patients with RHD injury or AHD injury in the First Affiliated Hospital of Nanjing Medical University between May 2014 and Nov. 2021. The injury types, causes, treatment and follow-up were analyzed. Postoperative grading of biliary patency were compared between IOC group (n=9) and non IOC group (n=11). Results For the 16 patients with RHD injury, the surgical treatments included primary repair with stent placement (n=8), simple repair (n=4), clamping and following delayed cholangiojejunostomy (n=3), suture PTCD applied for unsuccessful cholangiojejunostomy (n=1). 4 patients with AHD injury underwent surgical treatment including primary repair with T tube stent (n=1), delayed cholangiojejunostomy (n=1), and clamping (n=2). Postoperative results: for IOC group, grade A in 8, grade C in 1 for non IOC group, grade A in 3, grade B in 4, grade C in 3, and grade D in 1; grading of biliary patency in IOC group was better than that in non-IOC group (P<0.05). All patients were followed-up for 6~133 months, postoperative late complications included lithogenesis in RHD (n=2), cholangitis (n=3), and liver atrophy (n=1). Conclusion Comprehensive understanding of the anatomical characteristics of RHD injury and AHD injury, timely detection, and formulation of the individualized measures, which are the key points for iatrogenic bile duct injury caused by LC. IOC can significantly improve postoperative outcome.